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Peas Week 8 Soap Note Project

Peas Week 8 Soap Note Project

Gout Jane Doe

NSG 6435

Faculty

 

 

Chief Complaint

M.C. is a 55 year old Caucasian male presenting with complaints of pain, with redness and

swelling in his right great toe.

 

 

HPI

Historian: (include this information for patients <16 y/o and older patients PRN)

Patient is an obese male who reports pain, redness and swelling in right great toe(location) which started 3 days ago(Onset) and has progressively gotten worse(duration). He describes the pain as a burning constant(character) pain irritated with any touch or friction(aggravating). He tried over the counter ibuprofen(alleviating) and states it did mildly help the with the pain. The pain does radiate to the entire foot(radiation) and he cannot bear weight. He rates the pain as a 10/10 on the pain scale(severity). He mentions that he does have daily ethanol ingestion and was recently started on chlorthalidone for hypertension (HTN), which he feels contributed to the flare(temporal).

 

 

Medical History

• Kidney stones in 2012

• HTN

• Obesity

• No Surgeries

 

 

Medication Lists

• Ibuprofen – 800mg- tid

• Chlorthalidone 25mg- daily

• No Known Allergies

 

 

Family Medical History Summary

Father- Died at 72yrs old- hypertension, heart disease, and renal failure.

Mother- Died at age 65 of breast Cancer.

Sister- Age 55- Alive and well – HTN

Paternal Grandfather- Unknown

Paternal Grandmother – Died at age 82yr- Heart Disease

Maternal Grandmother- Dies at 87yr- Stroke- HTN and Diabetes

Paternal Grandfather- Died at 62 yrs in a car accident

 

 

Social History

C.M – Is divorced and lives alone. He was married for 20 years and has 1 male child age 28yr. He works full-time as a manager of a local Tires Plus. He rents an apartment in the local town in which he works. He is in a monagomous relationship with a female partner for past 2 years.

C.M. does not smoke. He drinks 2-3 alcoholic drinks per day. He reports sleeping 5-6 hours daily, and exercises twice weekly. He drinks 2-3 caffeinated beverages per day and eats at a fast food restaurant 4-5 days a week. He does eat beef daily.

He does report a history of methamphetamine abuse from ages 20-22. He was admitted to a drug rehabilitation program and has been drug free for 30 years.

 

 

Patient Profile

Activities of Daily Living (age appropriate): independent

Safety Practices: 2 firearms in home secured in a gun closet

Changes in daycare/school/after-school care: (address if appropriate)

Developmental History: (provide a history of development over the child’s lifespan. If

child is 1y/o or younger, provide birth history also)

 

 

Review of Systems

• CONSTITUTIONAL: No night sweats. No fatigue, malaise, lethargy. No fever or chills.

• HEENT: Eyes: No visual changes. No eye pain. No eye discharge. ENT: No runny nose. No epistaxis, No sinus pain. No sore throat. No odynophagia. No ear pain. No congestion.

• BREASTS: No breast pain, soreness, lumps, or discharge.

• RESPIRATORY: No cough. No wheeze. No hemoptysis. No shortness of breath.

• CARDIOVASCULAR: No chest pains. No palpitations.

• GASTROINTESTINAL: No abdominal pain. No nausea or vomiting. No diarrhea or constipation. No hematemesis. No hematochezia. No melena. BM- daily

• GENITOURINARY: No urgency. No frequency. No dysuria. No hematuria. No obstructive symptoms. No discharge. No pain. No significant abnormal bleeding.

 

 

Review of Systems

MUSCULOSKELETAL: musculoskeletal pain in right foot and toe and joint swelling in right great toe for past 3 days. No prior history of gout, No arthritis. No surgery in foot or ankle or leg. Difficulty bearing weight on right foot. “Warmth, pain, swelling, and extreme tenderness in a joint, usually a big toe joint (Podagra) Red or purplish skin around the affected joint (in-text citation from textbook).”

NEUROLOGICAL: No confusion or weakness. No headache or neck pain. No syncope or seizure.

PSYCHIATRIC: He gets occasionally confused.

SKIN: No rashes. No lesions. No wounds.

ENDOCRINE: No unexplained weight loss. No polydipsia. No polyuria. No polyphagia.

HEMATOLOGIC: No anemia. No purpura. No petechiae. No prolonged or excessive bleeding.

ALLERGIC AND IMMUNOLOGIC: No pruritus. No swelling.

 

 

Physical Examination

• Vital signs – Temp 99.1, Pulse 100, respiration -24, BP-151/95.

• Swelling and erythema in right great toe. “Nodules

• Pain and tenderness to right toe and right foot with palpation

• 2+ edema to right foot

 

 

Physical Examination

• “Warmth, redness, swelling, and decreased range of motion of the affected joint or joints. The initial episode is usually monoarticular in men. The first metatarsophalangeal (MTP) joint is the initial one involved in approximately half the patients. Acute synovitis of the first MTP joint of the big toe is referred to as podagra. Other joints involved (in decreasing order of frequency) are insteps, heels, knees, wrists, fingers, and elbows. In his classic description of the onset of an acute flare (in-text citation).”

 

 

Labs/Diagnostic Exam Results

CBC – white blood count elevated at 12,000.

His pertinent laboratory values reveal a mild leukocytosis and increased erythrocyte sedimentation rate.

Serum uric acid (SUA) level is 11.6 mg/dL. His SCr and BUN are elevated.

A synovial fluid aspirate of the affected toe joint contains white blood cells and monosodium urate crystals, confirming the diagnosis of gout.

• Comprehensive Chemistry – LFT’S- elevated- AST- 48, ALT- 38 GFR-<90,

• Renal Ultrasound –mild hydronephrosis of the left kidney noted. No renal abscess noted. No calculi or scarring noted.

 

 

Risk Factors for Gout

• Male

• Diet – limit foods with high –purine content

• Alcohol

• Obesity

• Renal Failure- High Blood Pressure

• Medications- Chlorthalidone

 

 

Diagnosis and Differential Diagnosis

• Acute Diagnosis – Gout M10.9

Differential Diagnosis

1. Pseudogout M11.20

2. Cellulitis L03.90

3. Rheumatoid Arthritis M06.9

• Chronic Diagnosis

1. Hypertension 401.9

2. Obesity E66.9

 

 

Diagnosis and Differential Diagnosis

Acute Diagnosis – Gout M10.90

Include the Definition of Gout

Include Pertinent Positives &

Negatives

Diff Dx – Pseudogout M11.20

Include the Definition of Pseudogout

Include Pertinent Positives &

Negatives

 

 

Diagnosis and Differential Diagnosis

Diff Dx – Cellutitis L03.90

Include the Definition of Gout

Include Pertinent Positives &

Negatives

Diff Dx – Rheumatoid Arthritis M06.90

Include Definition of Pseudogout

Include Pertinent Positives &

Negatives

 

 

National Clinical Guidelines

Hainer, B., Matheson, E., & Wilkes, R. (2014, December 15). Diagnosis, Treatment, and Prevention of Gout. Retrieved September 03, 2020, from https://www.aafp.org/afp/2014/1215/p831.html

Armstrong, C. (2014, October 01). JNC8 Guidelines for the Management of Hypertension in Adults. Retrieved September 03, 2020, from https://www.aafp.org/afp/2014/1001/p503.html

 

 

Treatment of Gout

Gout

• a) Medication-include dosage amounts and mg/kg for drug and number of days, b) Laboratory tests ordered

c) Diagnostic tests ordered

d) Vaccines administered this visit & vaccine administration forms given,

e) Non-pharmaceutical treatments

f) Patient/Family education including preventive care

(Hainer, Matheson, & Wilkes, 2014)

 

 

F)Teaching/Health Promotion

• Educate patient and family that frequent post-treatment surveillance for recurrent infection until 4–6 weeks postpartum is recommended. Monthly

urinalysis for culture and sensitivity for 3 months, use of Macrobid as

suppressive therapy, and initiating prevention strategies will reduce the risk

of acute pyelonephritis recurrence.

• Educate patients on strategies for preventing acute gout flares including adequate fluid intake, avoidance of high –purine foods(e.g., beef, seafood,

coffee, tea, colas, alcohol) medications as directed to reduce uric acid concentrations.

 

 

Treatment of HTN

HTN

• a) Medication-include dosage amounts and mg/kg for drug and number of days, b) Laboratory tests ordered

c) Diagnostic tests ordered

d) Vaccines administered this visit & vaccine administration forms given,

e) Non-pharmaceutical treatments

f) Patient/Family education including preventive care

(Armstrong, 2014)

 

 

Follow-up

g) Anticipatory guidance for visit (be sure to include exactly what you discussed during visit; review

Bright Futures website for this section), and

h) Follow-up appointment with detailed plan of f/u

 

 

References continued

Hainer, B., Matheson, E., & Wilkes, R. (2014, December 15). Diagnosis, Treatment, and

Prevention of Gout. Retrieved September 03, 2020, from

https://www.aafp.org/afp/2014/1215/p831.html

McCance, K. & Huether, S. (2014). Pathophysiology: the biologic for disease in adults and children, (7th

ed), St. Louis: MO; Elsevier/Mosby.

MeeOnn, C. & Amir-Ansari, B. (2012). Disease profile: pyelonephritis. Journal of Renal Nursing,

4(3), 128-130.

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